Tuesday, December 17, 2019

How Not To Die, and other food for thought

I recently read a book called How Not To Die by Michael Greger. Right off the bat, I thought the title was irksome- after all, which one of us is going to survive this crazy train called life? While there are people who dream of prolonging human life and go to extreme lengths to hack longevity, but I have no desire to live into my 90s and 100s. But I know this provocative book title is more along the lines of how not to die of diseases that you could prevent.

The book starts by saying that diet and lifestyle have been known for years to reverse heart disease. Why are doctors still prescribing drugs and surgery? Because there are other forces at work in medicine besides science. The US health system runs on a fee for service model where doctors get paid for pills and procedures prescribed. There is little profit motive for promoting whole foods.

The first part of How Not To Die examines the risk factors associated with a bunch of diseases that are some of the leading causes of death today, including heart disease, several cancers, Type 2 diabetes and infections. I was not a fan of these chapters because the author appears to cherry-pick studies (including some clearly poor quality studies, such as ones with tiny sample sizes) that fit what he believes, rather than looking at the overall body of evidence.

The second part of the book promotes a whole foods, plant-based diet as being the healthiest one. Greger uses a traffic light system:
Unprocessed plant foods get the green light;
Processed plant foods and unprocessed animal foods get the yellow light;
ultra-processed plant foods and processed animal foods are red light foods.

Unprocessed in this case means nothing bad added and nothing good taken away. Greger's suggested diet is free from all meat and dairy and eggs, and also from all added oils and fats.

He has a list of the daily dozen- 12 foods that should be consumed daily in appropriate serving sizes-
1. Beans and legumes
2. Berries
3. Other fruits
4. Greens
5. Cruciferous vegetables
6. Other vegetables
7. Flaxseeds
8. Nuts and seeds
9. Herbs and spices
10. Whole grains
11. Beverages- water, tea, coffee
12. Exercise

The minute I read through Greger's daily dozen foods, a mental picture popped up- a typical Maharashtrian taat or platter. A sample taat would have on it neatly arranged bowls of dal or amti made with lentils, sprouted beans usal, cooked greens, other stir-fried vegetables, a raw salad or koshimbir, a chutney with some combination of nuts, herbs, seeds and spices, chapatis made with whole wheat flour or bhakris made with jowar. A single meal would tick off most of these boxes.

 In fact most vegetarian meals in several Indian regional cuisines would look pretty similar to this. Even among the non-vegetarians, meat and fish is usually an occasional food eaten once or twice a week, and eaten in modest portions.

All in all, I'm on board with Greger's list of foods to eat on a daily basis for optimal health. We all would do so much better if we focused on eating more of these foods. I don't agree that this is the only diet that can be healthy. I particularly object to Greger's implication that a whole foods plant based diet is a panacea and can prevent all disease- that's just terribly misleading.

I've always wondered why India has such a massive Type 2 diabetes problem when most people eat simple, plant-based foods. One factor, of course, is genetics. It is said that genetics loads the gun and environment pulls the trigger. There are so many great things about the everyday Indian diet (see above) but there are some things that are not so good- white rice is eaten on a daily basis. Many people consume several cups of tea a day, each with spoonfuls of sugar. Oil is used plentifully in Indian cooking. Worse, dalda or hydrogenated vegetable oil is often used. Fried snacks and sweets are very popular. As is the case everywhere, affluent people have access to plentiful food and often simply eat too much. There are probably many other note-worthy risk factors not related to diet, such as stress caused by crowded city-dwelling and polluted air, and the lack of a cultural emphasis on exercise.

Even during the two decades when I was living in India, I saw some cultural shifts- the increased popularity and availability of foods such as bread made with refined flour, cookies, pastries, puffs and instant noodles. The eating-out culture took off in a big way. Weddings moved from traditional sit-down lunches (pangat) to lavish buffets.

(Greger, incidentally, talks about how great traditional Indian diets are and explains away the high prevalence of Type 2 diabetes by blaming it on ghee used in Indian cooking!)

All in all, this is a good book to read and think about. 2019 was a very positive year for me in terms of diet and exercise. I have slowly changed many of my eating and cooking habits, and learned more about strategies to keep myself and my family nourished and satisfied. This book made me think of a couple more changes I want to make- to buy and cook more greens, to use less oil in my cooking (it is so easy to go overboard) and to find ways to cut down even more on the fried snacks that are my kryptonite.

To give a real-life example, when I was making steel-cut oats kheer, I wanted to toast the oats in ghee to make the kheer even more flavorful. On second thought, I didn't. I skipped that added fat and the kheer was wonderful anyway. The point is not that all fats are bad, or that I am personally going to cut out all added oils and fats, but that it is incredibly easy to add fats and oils into dishes that don't need them.

A good quote from How Not To Die:
 “Eating a whole-food, plant-based diet and returning your brain’s dopamine sensitivity to its healthy, normal levels can help you live life to the fullest and allow you to experience greater joy, satisfaction, and pleasure from all the things you do- not just what you eat.”
The premise of How Not To Die is that most diseases that people die from are preventable and that we as individuals have the power to choose an optimal diet that will keep us healthy. Funny enough, right after reading this book, I read another book called Well: What We Need to Talk About When We Talk About Health by Sandro Galea, and this book has a very different perspective.

Galea says that much of our conversation about health has to do with lifestyle and making choices for better health. And that this is wrong. The range of choices depends on context, factors beyond our immediate control or even awareness. There are inherent limits to personal choice. Our health is shaped by things that are much larger than any individual- things like policies, and the places that we end up living in, and sheer luck.

Where does the truth lie? Somewhere in the middle, I believe. There are many things we can't control and many that we can. There are those (me included) who, through a large dose of luck, have education and privilege and a comfortable paycheck, which gives us a pretty wide range of choices. People like us can and should exercise (no pun intended) good lifestyle choices.

Here's to a healthy 2020 for us all! 


  1. I feel the eating out culture in cities and the fact that majority of the restaurants have all you can eat buffets culture is a major downfall (at least in the cities). I feel as long as I can limit my outside food and eat the way I have grown up eating (I am from Pune, so the typical marathi food) my health and immunity stays good. And irrespective of what books/studies say I for the life of me cannot avoid ghee. Especially in winters, ghee-jaggery is a daily thing. Anything that blames just one ingredient for something as widespread as diabetes raises a red flag in my mind.
    From all the books that I have read on food and nutrition I keep going back to Michael Pollan's Food Rules. A short and informative read, I love that he has a very holistic and non-overwhelming approach to food that combines common sense and ancient wisdom. Hope you have a healthy 2020!

    1. Neha- We too feel our best when home-cooked meals are the staple and eating out is reserved for a once a week or so treat. Portion sizes in US restaurants can be astonishingly huge. I agree that Michael Pollan's food rules are sensible and can accommodate a variety of diets.

  2. Sounds very interesting and it is great to read your critical response. It sounds like what Greger is suggesting is fairly common sense and what Galea discusses gives some reasons for why so many of us don't always adhere to common sense.

    1. Johanna- Galea's book is very meditative and really emphasized the systemic challenges that exist, particularly for the underprivileged. It is a short book with a clear message, only it made me feel a little helpless.

  3. This is so true and a very thoughtful summary. Although I disgree with Gregor's take on ghee. I have no scientific evidence here to prove or disprove my point. But I have been following Rijuta Diwekar more recently and she encourages the use of ghee in a big way, suggesting that ghee helps assimilate many vitamins and minerals. Again, I am not sure if she has evidence to back it up, mainly anecdotal but sounds very much like what my grandmother used to say. Recently I have strayed back to my roots and o plentiful of rice, sambar, rasam and vegetables in my diet - this has been good for my health.
    I agree with your thoughts on modern Indian lifestyle and also wanted to add that physical activity is lacking there due to the urbanization and lifestyle changes (similar to any other developed country).
    I have been following Feel Better Live More podcast which has been very interesting.

    1. Sangeetha- When I read Diwekar's books a few years ago, that was my primary takeaway, that everything she says is anecdotal and subjective. While I did not understand why Gregor pinpointed ghee as the one factor which somehow undermined Indian diets, his overall caution about added fats in the diet makes some sense- because spoonfuls of fat (whether oil, ghee, butter) are so high in calories.

  4. I have long hopped off the dietary recommendations see-saw and just eat what makes me feel good and function optimally: lots of vegetables and fruits, some carbs (I love my rice and pasta!) and occasional sweet treats. I don't count calories or measure my fat. In spite all of this a mutant gene caused me to have cancer. I treated it and hopefully this saga is behind me, for now at least, and am back to eating what I enjoy. I refused and still refuse to follow any fad diets. I firmly believe that there is no one-size-fits all eating plan. Michael Pollan's advice is great because it is based on common sense!!

    1. Dear Kamini- It pains me to learn that you had to go through cancer treatment. I am glad it is behind you- sending you fervent wishes that it stays that way.

      I completely agree with you that there is no one size fits all eating plan and it is up to us as individuals to find something that works for us- i.e., keeps us fueled and satisfied and at a healthy weight without feeling of deprivation. Getting there isn't easy though, which is what prompts me to read book and think about these issues a lot. Eating well is simple but not easy. (Of course, a big issue is that we as a society are subsidizing the wrong things and have ended up with this toxic food environment where ultra-processed foods are the cheapest and most available ones around).

  5. Nupur, my son recently told me about Dr Greger. All of Dr Greger's recommendations are solid undoubtedly but I am not sure if the omission of all oils and fats is right. For 30 years now in Australia, I have only ever used EVO for my cooking. I use Australian cold pressed Macadamia nut oil and Avocado oils on salads. We are all vegetarian and I make ghee at home. We enjoy moderate amounts of ghee on khichadi and masale bhaat. We eat fresh and rarely eat out. We have now incorporated IF in our lifestyle. I am off statins, our fasting insulin levels are fantastic, Sanjay's hypertension is under control. So, here's wishing you and family and Duncan and all the readers a very happy, healthy plant based new year

    1. Shubha- Yes, there is so much daylight between consuming zero added oils and fats on one end and eating mostly fried and oily foods at the other end. My personal choice at least at this time is to be on some reasonable point of this spectrum. Yours is a success story where the choices you have made have translated into actual health benefits. That is really the goal of thinking of one's diet and not just going with the flow and eating "whatever".

  6. While I am not, in general, a fan of diets, I have followed the Weight Watchers programne with success. The programme is based on common sense. It allocates points to every food based on fat, carbs etc, tells you how many points you should eat daily in order to lose a healthy amount of weight on a weekly basis and lets you plan your diet around those points. You can earn more points from exercise and there is a weekly bonus for some indulgdnce. No food is off limits but when you realise that a tablespoon of oil is 4 points and a cup of cooked rice even more, you soon learn to balance your diet. Fruits and vegetables are zero points so guess what you learn to load up on! In tbe end,it's mostly a combination of balance, genetics and environment.

    1. Amber- That makes a lot of sense and I have always thought that WW is practical that way. Another analogy I have found useful is that every day you have a certain amount to spend and to learn to spend it wisely.


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